CareFirst Careers

Vice President of Special Investigations

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Resp & Qualifications

PURPOSE: The Vice President, Payment Integrity and Oversight ensures the successful operation and delivery of Payment Integrity services by securing a payment cycle that achieves accurate and timely transactions. The Vice President is also responsible for the detection, investigation, and mitigation of loss related to fraud, waste and abuse.

This role leads teams accountable for controlling fraud, waste & abuse (FWA), subrogation activities, including worker’s compensation, vendor  recovery and Payment Integrity efforts. He/she sets strategy for the Company’s fraud fighting and anti-fraud efforts and coordinates with the Office of Corporate Counsel to ensure the Company s efforts to detect, prevent and investigate FWA by providers, members, employees or others meet all necessary regulatory requirements.

The role requires cross-functional work to ensure department and corporate strategies are executed and achieved enterprise-wide.

Under the general direction of the Executive Vice President & General Counsel the incumbent’s accountabilities include, but are not limited to:

Strategic Planning and Budget Management:

  • Provides strategic guidance, direction and management to support a workforce in the areas of FWA, subrogation activities, Vendor recovery and Payment Integrity.
  • Analyzes, evaluates and recommends strategic plans to coordinate with the future vision of payment integrity and oversight and the company.
  • Establishes and communicates current and long-range departmental goals and objectives and monitors results on an ongoing basis, adjusting plans and performance expectations to achieve targeted results.
  • Develops, formulates, recommends and implements decisions regarding policy, standards, methods, procedures and functions.
  • Ensures productivity meets or exceeds service and quality standards
  • Determines strategic technical direction for both FWA and Payment Integrity and develops and manages an annual budget necessary to support the internal and external resources necessary to achieve the set goals and operational plan.

Fraud, Waste and Abuse:

  • Oversees all FWA investigations by providing direction and strategy to the FWA associates
  • Ensures staff are fully aware of objectives and that they maintain suitable records, reports, and files with adequately documented audit plans, case work, and reporting for all audits performed, and which adhere to departmental policies and procedures. 
  • Applies industry specific knowledge, company specific knowledge, and knowledge of systems and operational functions, ensuring that issues developed from these audit tools assists in developing the scope of audits as well as contributing to the data integrity associated with audit cases for recovery, restitution and prosecution when necessary
  • Collaborates with all internal stakeholders, including but not limited to: the Medical Directors, Finance, Operational Units, Networks Management and Provider Relations, the Pharmacy Benefit Manager, and industry partners to provide education and training to providers and determine of the course of action to be taken with providers who do not change aberrant billing behavior. Collaborates with local, state, and federal law enforcement agencies and national anti-fraud associations to identify new cases, assist with existing cases and conduct joint investigations.
  • Interacts with providers, members, third parties and attorneys on case investigations and reports; responds to internal and external inquiries regarding investigative activity and provider case settlements in order to promote positive corporate public relations with providers and the community; works closely with  the Office of Corporate Counsel on these matters.

Payment Integrity:

  • Integrates and coordinates claims recovery opportunities from across the organization.
  • Provides root cause analysis of leakage results across the organization for Operations mitigation.
  • Identifies and implements training and education opportunities across the organization to improve initial claim processing results.
  • Identifies and manages vendors that optimize cost containment actions including Subrogation vendor.
  • Ensures all jurisdictional, state and federal compliance, audit and regulatory requirements are met.
  • Utilizes extensive understanding of payment integrity metrics and best practices to identify opportunities for process improvement.
  • Builds, manages, develops and continuously improves the company’s payment integrity to meet the diverse and dynamic needs of a growing, evolving organization.


  • Develops an effective team through hiring, training, coaching and providing ongoing and constructive feedback.
  • Conducts regular department/unit/office meetings to inform staff of performance, results and issues effective company and/or claims operations.
  • Develops and manages department budget, including monitoring expenditures and reporting results.
  • Communicates operational results to executive leadership using standardized reports, dashboards and frequent verbal updates through participation in management meetings and operational review processes.
  • Keeps abreast of industry developments, particularly those which impact claims.
  • Stays current with technology, processes and best practices and leverage knowledge to identify opportunities for training and process improvement.

Performs other duties as necessary or assigned.


• Bachelor s Degree in business administration (accounting, finance), management sciences, nursing, criminal justice, and/or related technology fields .  In lieu of a Bachelor’s Degree, an additional 4 years of relevant experience is required.
• Minimum of ten years of experience in fraud and abuse investigations or health care fraud experience.
• At least one professional certification as a Certified Public Accountant (CPA), Certified Fraud Examiner (CFE), or Accredited Healthcare Fraud Investigator (AHFI).
• 5 years of experience leading and managing subrogation activities and claims recovery for an insurance company.
• 10 years of progressive management experience.
• Familiarity with applicable regulations governing healthcare fraud, waste and abuse.
• Extensive knowledge of Medicare and Medicaid health-care regulations, legislation and laws, auditing reports and system functions, with in-depth operational experience of medical billing, coding and provider claims processing and adjustment.


• Demonstrated leadership, coaching and mentoring skills for all levels of staff.
• Excellent written, verbal, analytical, organizational, and presentation skills.
• Excellent time management, prioritization, and delegation skills.
• Knowledge of investigatory best practices and methodologies and tools, including ability to manage investigation resources.
• Strong data analytical skills.  Ability to assess complex problems and recommend appropriate solutions related to issues at all levels, internally and externally.
• Experience in evaluating claims using various forensic techniques and knowledge of related legal/regulatory issues.
• Demonstrated ability in developing and maintaining effective working relationships with a variety of federal, state, and local law enforcement agencies.  Ability to communicate effectively, including but not limited to, annual SIU reporting to the federal government as required and Departments of Insurance.
• Proven effective communication, interpersonal, and motivational skills.  Objective collaborative approach.
• Demonstrated ability to think strategically and to proactively manage the implementation of broad based and strategic initiatives.  Demonstrated ability to anticipate future trends accurately.
• Demonstrated ability to develop innovative long-term strategies/plans based on industry analysis, local markets and organizational capabilities.
• Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time.  Must be able to meet established deadlines and handle multiple demands from internal and external stakeholders, within set expectations for service excellence.
• Must commit to frequent travel to multiple staff sites and CareFirst offices.

Master's degree or MBA from an accredited institution


Special Investigations

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply:

Closing Date

Please apply before: 10/06/2019

Federal Disc/Physical Demand

Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

The associate is primarily seated while performing the duties of the position.  Occasional walking or standing is required.  The hands are regularly used to write, type, key and handle or feel small controls and objects.  The associate must frequently talk and hear.  Weights of up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

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